high school hockey league of nassau...

29
High School Hockey League of Nassau County Coach’s Binder

Upload: others

Post on 08-Aug-2020

0 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

High School Hockey

League of Nassau County

Coach’s Binder

Page 2: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

High School Hockey League of Nassau County Coach’s Binder 2018-2019

Table of Contents

1. Signed Roster

2. Birth Certificate or Other I.D.

3. AAU Registration Cards

4. Waiver of Liability

5. Consent to Treat

6. School Certification

7. Player Eligibility Summary

8. Game Scoresheets

9. USA Hockey, AAU & NFHS Coaching Certifications

10. Coach’s Waiver of Liability

11. Codes of Conduct

12. Concussion Recognition

Page 3: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

HSHLNC Roster

Page 4: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Team:

PLAYERS (ATHLETES)

Last, First Name DOB SIGNATURE ADDRESS CITY ZIP

AAU

REGISTRATION

NUMBER

SCHOOL GRADE Email Address

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

NAME (Last, First) POSITION E‐ Mail ADDRESS CITY Telephone NumberAAU REGISTRATION

NUMBER

USAH CEP LEVEL &

CERTIFICATION NO

EXP DATE

1 Coach

2 A/C

3 A/C

4 A/C

5 MGR.

TEAM OFFICIALS (Non-Athletes)

HSHLNC Team Roster

2018-2019

Page 5: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

AAU Registration Cards

Page 6: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Waiver of Liability

Page 7: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

NYSCSH Waiver of Liability, Release

Assumption of Risk & Indemnity Agreement It is the purpose of this agreement to exempt, waive and relieve releasees from liability for personal injury, property damage, and wrongful death, including if caused by negligence, including the negligence, if any, of releasees. “Releasees” include AAU Hockey, its affiliate associations, member teams, event hosts, other participants, coaches, officials, sponsors, advertisers, and each of them, their officers, directors, agents and employees. For and in consideration of participant’s registration with AAU Hockey, it’s affiliate, local association and member teams and being allowed to participate in AAU Hockey events and member team activities, the participant (and the parent(s) or legal guardian(s) of participant if applicable) waive, release and relinquish any and all claims for liability and cause(s) of action, including for personal injury, property damage, or wrongful death occurring to participant, arising out of participation in AAU Hockey events, member team activities, the sport of ice hockey, and/or activities incidental thereto, whenever or however they occur and for such period said activities may continue, and by this agreement any such claims, rights, and causes of action that participant (and participant’s parent(s) or legal guardian(s), if applicable) may have are hereby waived, released and relinquished, and participant (and parent(s)/guardian(s) if applicable) does (do) so on behalf of my/our and participant’s heirs, executors, administrators and assigns. Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume all risks relating to ice hockey and any member team activities, and understand that ice hockey and member team activities involve risks to participant’s person including bodily injury, partial or total disability, paralysis, and death, and damages which mat arise there from and that I/we have full knowledge of said risks. These risks and dangers may be caused by the negligence of the participant or the negligence of others, including the “releasees” identified below. These risks and dangers include but are not limited to, those arising from participating with bigger, faster and stronger participants, and these risks and dangers will increase if participant participates in ice hockey and member team activities in an age group above that which participant would normally participate in. I/We further acknowledged that there may be risks and dangers not known to us or are not reasonably foreseeable at this time. Participant (and participant’s parent(s) /guardian(s), if applicable) acknowledge, understand and agree that all risks and dangers described throughout this agreement, including those caused by negligence of participant and/or others, are included within the waiver, release and relinquishment described in the preceding paragraph. I/we agree to abide by and be bound under the rules of AAU Hockey, including the By-Laws of the corporation and the arbitration clause provisions, as currently published. Copies are available to AAU Hockey members upon written request. Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume the risks, if any, arising from the conditions and use of ice hockey rinks and related premises and acknowledges and understands that included within the scope of this waiver and release is any cause of action (including any because of action based on negligence), arising from the performance, or failure to perform maintenance, inspection, supervision or control of said areas and for the failure to warn of dangerous conditions existing at said rinks, for negligent selection of certain releases, or negligent supervision or instruction by releasees. If the law in any controlling jurisdiction renders any part of this agreement unenforceable, the remainder of this agreement shall nevertheless remain enforceable to the full extent, if any, allowed by controlling law. This agreement affects your legal rights, and you may wish to consult an attorney concerning this agreement. Participant (and participant’s parent(s)/guardian(s), if applicable), agree if any claim for participant’s personal injury or wrongful death is commenced against releasees, he/she shall defend, indemnify and save harmless releasees from any and all claims or causes of action by whomever of wherever made or presented for participant’s personal injuries, property damage or wrongful death. Participant (and participant’s parent(s)/guardian(s), if applicable), acknowledge that they have been provided and read the above paragraphs and have not relied upon any representations of releasees, that they are fully advised of the potential dangers of ice hockey and understand these waivers and releases are necessary to allow amateur ice hockey to exist in it’s present form. Significant exclusions may apply to AAU Hockey’s insurance policy, which could affect any coverage. For example, there is no liability coverage for claims of one player against another player. Read your brochure carefully and, if you have any questions, contact AAU Hockey or a District League Official.

___________________________ Age _______ Date Signed ______________

PARTICIPANT SIGNATURE

PARTICIPANT NAME (PRINT)

Date Signed ______________

PARENT OR GUARDIAN SIGNATURE (Ii Participant is 17 years of age or younger)

This form to be retained by local program

Page 8: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Consent to Treat

Page 9: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

NYSCSH CONSENT TO TREAT

This is to certify that on this date, I ___________________________________as parent or guardian

of _______________________________(athlete participant), or for myself as an adult participant,

give my consent to AAU Hockey and its medical representative to obtain medical care from any

licensed physician, hospital, or clinic for the above mentioned participant, for any injury that could

arise from participation in AAU Hockey sanctioned events.

If said athlete is covered by any insurance company, please complete the following:

Insurance Company ____________________________________________________

Policy Number: _________________________________________________________

Parent/Guardian/Adult Participant Signature: __________________________Date: ______

For more information or insurance claim forms, go to aausports.org

Page 10: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

School Certification

Page 11: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Scoresheets

Page 12: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

High School Hockey League of Nassau CountyPlayer Eligibility Game Log

Game Date

STATUS Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Played

Injured

Suspen

ded

Player Game

1 0 0 0

2 0 0 0

3 0 0 0

4 0 0 0

5 0 0 0

6 0 0 0

7 0 0 0

8 0 0 0

9 0 0 0

10 0 0 0

11 0 0 0

12 0 0 0

13 0 0 0

14 0 0 0

15 0 0 0

16 0 0 0

17 0 0 0

18 0 0 0

19 0 0 0

20 0 0 0

21 0 0 0

22 0 0 0

23 0 0 0

24 0 0 025 0 0 0

19 20 Total13 14 15 16 17 187 8 9 10 11 121 2 3 4 5 6

Page 13: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

USA Hockey, AAU & NFHS Coaching

Certifications

Page 14: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Coach’s Waiver of Liability

Page 15: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Codes of Conduct

Page 16: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

NY01/OGARJ/1482138.1

HSHLNC

PLAYER CODE OF CONDUCT Preamble The essential elements of character-building and ethics in sports are embodied in the concept of sportsmanship and six core principles: trustworthiness, respect, responsibility, fairness, caring, and good citizenship. The highest potential of sports is achieved when competition reflects these "six pillars of character." 1 I therefore agree:

1. I will demonstrate good sportsmanship by showing respect and courtesy, and by

demonstrating positive support for all players, coaches, and officials at every game, practice or other sporting event.

2. I will not engage in any kind of unsportsmanlike conduct with any official, coach, player, or parent such as taunting; refusing to shake hands; or using profane language or gestures.

3. I will attend every practice and game that I can, and will notify my coach if I cannot. I will be on time for practice and games.

4. I will inform the coach of any physical disability or ailment that may affect my ability to safety play or practice or the safety of others.

5. I will do my best to listen and learn from my coaches.

6. I will treat my coaches, other players, officials and fans with respect regardless of race, sex, creed, or abilities, and I will expect to be treated accordingly.

7. I deserve to have fun during my sports experience and will alert parents or coaches if it stops being fun!

8. I deserve to play in an environment that is free of drugs, tobacco, and alcohol and expect adults to refrain from their use at all youth sports events.

9. I will do my very best in school.

10. I will remember that sports and are an opportunity to learn and have fun.

11. I will learn and abide by the rules of the game and the by-laws and regulations of the League.

Page 17: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

NY01/OGARJ/1482138.1

12. I will not engage in unsportsmanlike conduct with any coach, parent, player, participant, league official or any other attendee.

13. I will not engage in any behavior which would endanger the health, safety, or well being of a coach, parent, player, participant, league official or any other attendee.

14. I will not engage in the use of profanity while attending or participating in a youth sports event.

15. I will not engage in any hazing (including cyber-bullying), verbal, physical or motional abuse or threats aimed at any player, coach, on-ice official, league official, parent, participant, or any other attendee.

16. I will not engage in any racial, sexual, religious or other forms of discrimination

17. I will not initiate a fight or scuffle with any coach, parent, player, participant, league official, or any other attendee.

I also agree that if I fail to abide by the aforementioned rules and guidelines, I will be subject to disciplinary action that could include, but is not limited to the following:

o Verbal warning by official, head coach, and/or head of league organization o Written warning o Game suspension with written documentation of incident kept on file by

organizations involved o Game forfeit through the official or coach o Season suspension

Player Signature

_____________________________________________________________

Print Player Name _____________________________________________________________ Parent Signature _____________________________________________________________ Print Parent Name _____________________________________________________________

Page 18: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

NY01/OGARJ/1406084.1

HSHLNC

PARENT CODE OF CONDUCT

Preamble

The essential elements of character-building and ethics in sports are embodied in the concept of

sportsmanship and six core principles: trustworthiness, respect, responsibility, fairness, caring,

and good citizenship. The highest potential of sports is achieved when competition reflects these

"six pillars of character." 1

I therefore agree:

1. I will not force my child to participate in sports.

2. I will remember that children participate to have fun and that the game is for youth, not adults.

3. I will inform the coach of any physical disability or ailment that may affect the safety of my

child or the safety of others.

4. I will learn the rules of the game and the policies of the league.

5. I (and my guests) will be a positive role model for my child and encourage sportsmanship by

showing respect and courtesy, and by demonstrating positive support for all players, coaches,

officials and spectators at every game, practice or other sporting event.

6. I (and my guests) will not engage in any kind of unsportsmanlike conduct with any official,

coach, player, or parent such as booing and taunting; refusing to shake hands; or using profane

language or gestures.

7. I will not encourage any behaviors or practices that would endanger the health and well-being

of the athletes.

8. I will teach my child to play by the rules and to resolve conflicts without resorting to hostility

or violence.

9. I will demand that my child treat other players, coaches, officials and spectators with respect

regardless of race, creed, color, sex or ability.

10. I will teach my child that doing one's best is more important than winning, so that my child

will never feel defeated by the outcome of a game or his/her performance.

Page 19: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

NY01/OGARJ/1406084.1

11. I will praise my child for competing fairly and trying hard, and make my child feel like a

winner every time.

12. I will never ridicule or yell at my child or other participant for making a mistake or losing a

competition.

13. I will emphasize skill development and practices and how they benefit my child over

winning. I will also deemphasize games and competition in the lower age groups.

14. I will promote the emotional and physical well-being of the athletes ahead of any personal

desire I may have for my child to win.

15. I will respect the officials and their authority during games and will never question, discuss,

or confront coaches at the game field, and will take time to speak with coaches at an agreed upon

time and place.

16. I will demand a sports environment for my child that is free from drugs, tobacco, and alcohol

and I will refrain from their use at all sports events.

17. I will refrain from coaching my child or other players during games and practices, unless I

am one of the official coaches of the team.

I understand that a game may be stopped by an Off-Ice or On-Ice Official when if I or any parent

or spectator displays inappropriate or disruptive behavior which interferes with other spectators

or the game. The Off Ice or On-Ice Officials will identify the violator and remove the offending

person from the game area or arena. Removed violators will incur a minimum mandatory 3-

game suspension from that team’s games, and must appear before the League Disciplinary

Committee before the offending person will be allowed to return to any League games.

Violators are subject to further disciplinary action by the Disciplinary Committee.

I agree that if I fail to abide by the aforementioned rules and guidelines, I will be subject to

disciplinary action that could include, but is not limited to the following:

o Verbal warning by official, head coach, and/or head of league organization

o Written warning

o Parental game suspension with written documentation of incident kept on file by

organizations involved

o Game forfeit through the official or coach

o Parental season suspension

Parent/Guardian Signature________________________________________________________

Print Name____________________________________________________________

Page 20: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Town of Oyster Bay Department of Parks Spectator and Participant Code of Conduct

and Zero Tolerance Policy

The Town of Oyster Bay, in an attempt to provide a safe and fair playing environment, has adopted the following code of conduct and zerc tolerance policy:

Zero tolerance essentially means that all organizations, participants and spectators involved in our programs and/or. using our facilities will act in a manner that is sportsman-like and will be respectful to fellow spectators. participants, coaches, referees/umpires and Town employees.

Behavior is outlined as, but not limited to the following: any form of disrespect, insubordination, abusive language, fighting, destruction of property and/or equipment and any behavior deemed as criminal and/or abusive to other players, spectators, coaches and Town employees.

It is the responsibility of these organizations, spectators, and participants to enforce and comply with this zero tolerance policy and code of conduct. Failure to do so will not be tolerated.

Town of Oyster Bay staff has the right to remove any individual(s) from its facilities that do not comply with this policy.

Zero Tolerance Agreement

I, the undersigned. have read and received a copy of the Zero Tolerance Policy and understand the potential ramifications of negative or abusive conduct at Town of Oyster Bay youth programs and facilities. I furthermore pledge to adhere to these guidelines and support the Town of Oyster Bay to our fullest ability.

Legal Guardian

Printed Name:

Signature: Date:

Page 21: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Concussion Recognition & Policy

Page 22: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat
Page 23: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat
Page 24: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat
Page 25: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Concussions: The Invisible InjuryStudent and Parent Information Sheet

FactS about concuSSIonS accordIng to the center For dISeaSe control (cdc)

l An estimated 4 million people under age 19 sustain a head injury annually. Of these approximately 52,000 die and 275,000 are hospitalized.l An estimated 300,000 sports and recreation related concussions occur each year.l Students who have had at least one concussion are at increased risk for another concussion.

In New York State in 2009, approximately 50,500 children under the age of 19 visited the emergency room for a traumatic brain injury and of those approximately 3,000 were hospitalized.

requIrementS oF School dIStrIctS

Education:l Each school coach, physical education teacher, nurse, and athletic trainer will have to complete an approved course on concussion management on a biennial basis, starting with the 2012-2013 school year. j School coaches and physical education teachers must complete the CDC course. (www.cdc.gov/concussion/HeadsUp/online_training.html) j School nurses and certified athletic trainers must complete the concussion course. (http://preventingconcussions.org)

Information: l Provide concussion management information and sign off with any parental permission form. l The concussion management and awareness information or the State Education Department’s web site must be made available on the school web site, if one exists.

Removal from athletics:l Require the immediate removal from athletic activities of any pupil that has or is believed to have sustained a mild traumatic brain injury. l No pupils will be allowed to resume athletic activity until they have been symptom free for 24 hours and have been evaluated by and received written and signed authorization from a licensed physician. For interscholastic athletics, clearance must come from the school medical director. j Such authorization must be kept in the pupil’s permanent heath record. j Schools shall follow directives issued by the pupil’s treating physician.

SymPtomS

Symptoms of a concussion are the result of a temporary change in the brain’s function. In most cases, the symptoms of a concussion generally resolve over a short period of time; however, in some cases, symptoms will last for weeks or longer. Children and adolescents are more susceptible to concussions and take longer than adults to recover.

It is imperative that any student who is suspected of having a concussion is removed from athletic activity (e.g. recess, PE class, sports) and remains out of such activities until evaluated and cleared to return to activity by a physician.

Symptoms include, but are not limited to:l Decreased or absent memory of events prior to or immed- iately after the injury, or difficulty retaining new informationl Confusion or appears dazedl Headache or head pressurel Loss of consciousnessl Balance difficulties, dizziness, or clumsy movementsl Double or blurry visionl Sensitivity to light and/or soundl Nausea, vomiting and/or loss of appetite l Irritability, sadness or other changes in personalityl Feeling sluggish, foggy or light-headedl Concentration or focusing problemsl Drowsinessl Fatigue and/or sleep issues – sleeping more or less than usual

Students who develop any of the following signs, or if signs and symptoms worsen, should be seen and evaluated immediately at the nearest hospital emergency room.l Headaches that worsenl Seizuresl Looks drowsy and/or cannot be awakenedl Repeated vomitingl Slurred speechl Unable to recognize people or placesl Weakness or numbing in arms or legs, facial droopingl Unsteady gaitl Change in pupil size in one eyel Significant irritabilityl Any loss of consciousnessl Suspicion for skull fracture: blood draining from ear or clear fluid from the nose

concuSSIon deFInItIon

A concussion is a reaction by the brain to a jolt or force that can be transmitted to the head by an impact or blow occurring anywhere on the body. Essentially a concussion results from the brain moving back and forth or twisting rapidly inside the skull.

Page 26: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

State educatIon dePartment’S guIdance For concuSSIon management

Schools are advised to develop a written concussion manage-ment policy. A sample policy is available on the NYSPHSAA web site at www.nysphsaa.org. The policy should include: l A commitment to reduce the risk of head injuries.l A procedure and treatment plan developed by the district medical director.l A procedure to ensure proper education for school nurses, certified athletic trainers, physical education teachers, and coaches.l A procedure for a coordinated communication plan among appropriate staff.l A procedure for periodic review of the concussion management program.

return to learn and return to Play ProtocolS

Cognitive Rest: Activities students should avoid include, but are not limited to, the following:l Computers and video gamesl Television viewingl Textingl Reading or writingl Studying or homeworkl Taking a test or completing significant projectsl Loud musicl Bright lights

Students may only be able to attend school for short periods of time. Accommodations may have to be made for missed tests and assignments.

Physical Rest: Activities students should avoid include, but are not limited to, the following:l Contact and collisionl High speed, intense exercise and/or sportsl High risk for re-injury or impactsl Any activity that results in an increased heart rate or increased head pressure

Return to Play Protocol once symptom free for 24 hours and cleared by School Medical Director:

day 1: Low impact, non strenuous, light aerobic activity.

day 2: Higher impact, higher exertion, moderate aerobic activity. No resistance training.

day 3: Sport specific non-contact activity. Low resistance weight training with a spotter.

day 4: Sport specific activity, non-contact drills. Higher resistance weight training with a spotter.

day 5: Full contact training drills and intense aerobic activity.

day 6: Return to full activities with clearance from School Medical Director.

Any return of symptoms during the return to play protocol, the student will return to previous day’s activities until symptom free.

concuSSIon management team

Schools may, at their discretion, form a concussion management team to implement and monitor the concussion management policy and program. The team could include, but is not limited to, the following:l Studentsl Parents/Guardiansl School Administratorsl Medical Directorl Private Medical Providerl School Nursel Director of Physical Education and/or Athletic Directorl Certified Athletic Trainerl Physical Education Teacher and/or Coachesl Classroom Teachers

other reSourceS

l New York State Education Department

http://www.p12.nysed.gov/sss/schoolhealth/schoolhealthservicesl New York State Department of Healthhttp://www.health.ny.gov/prevention/injury_prevention/concussion/htm l New York State Public High School Athletic Associationwww.nysphsaa.org/safety/ l Center for Disease Control and Preventionhttp://cdc.gov/TraumaticBrainInjuryl National Federation of High Schoolswww.nfhslearn.com – The FREE Concussion Management course does not meet education requirement.l Child Health Plushttp://www.health.ny.gov/health_care/managed_care/consumer_guide/about_child_health_plus.htm l Local Department of Social Services – New York State Department of Healthhttp://www.health.ny.gov/health_care/medicaid/ldss/htm l Brain Injury Association of New York Statehttp://www.bianys.org l Nationwide Children’s Hospital – Concussions in the Classroomhttp://www.nationwidechildrens.org/concussions-in-the-classroom l Upstate University Hospital – Concussions in the Classroomhttp://www.upstate.edu/pmr/healthcare/programs/concussion/classroom.php l ESPN Video – Life Changed by Concussionhttp://espn.go.com/video/clip?id=7525526&categoryid=5595394 l SportsConcussions.orghttp://www.sportsconcussions.org/ibaseline/ l American Association of Neurological Surgeonshttp://www.aans.org/Patient%20Information/Conditions%20and%20Treatment/Concussion.aspxl Consensus Statement on Concussion in Sport – Zurichhttp://sportconcussions.com/html/Zurich%20Statement.pdf

Page 27: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

CONCUSSION CHECKLIST (Revision #3)

Name: Age: Grade: Sport:

Date of Injury: Time of Injury:

On Site Evaluation

Description of Injury:

Has the athlete ever had a concussion? Yes No

Was there a loss of consciousness? Yes No Unclear

Does he/she remember the injury? Yes No Unclear

Does he/she have confusion after the injury? Yes No Unclear

Symptoms observed at time of injury:

Dizziness Yes No Headache Yes No

Ringing in Ears Yes No Nausea/Vomiting Yes No

Drowsy/Sleepy Yes No Fatigue/Low Energy Yes No

“Don’t Feel Right” Yes No Feeling “Dazed” Yes No

Seizure Yes No Poor Balance/Coord. Yes No

Memory Problems Yes No Loss of Orientation Yes No

Blurred Vision Yes No Sensitivity to Light Yes No

Vacant Stare/ Sensitivity to Noise Yes No

Glassy Eyed Yes No

* Please circle yes or no for each symptom listed above.

Other Findings/Comments:

Final Action Taken: Parents Notified Sent to Hospital

Evaluator’s Signature: Title:

Address: Date: Phone No.:

Page 28: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Physician Evaluation (Revision #3)

Date of First Evaluation: Time of Evaluation:

Date of Second Evaluation: Time of Evaluation:

Symptoms Observed: First Doctor Visit Second Doctor Visit

Dizziness Yes No Yes No

Headache Yes No Yes No

Tinnitus Yes No Yes No

Nausea Yes No Yes No

Fatigue Yes No Yes No

Drowsy/Sleepy Yes No Yes No

Sensitivity to Light Yes No Yes No

Sensitivity to Noise Yes No Yes No

Anterograde Amnesia Yes No N/A N/A

(after impact)

Retrograde Amnesia Yes No N/A N/A

(backwards in time from impact)

* Please indicate yes or no in your respective columns. First Doctor use column 1 and second Doctor use column 2.

First Doctor Visit:

Did the athlete sustain a concussion? (Yes or No) (one or the other must be circled) ** Post-dated releases will not be accepted. The athlete must be seen and released on the same day.

Please note that if there is a history of previous concussion, then referral for professional management by a

specialist or concussion clinic should be strongly considered. Additional Findings/Comments:

Recommendations/Limitations:

Signature: Date:

Print or stamp name: Phone number:

________________________

Second Doctor Visit: *** Athlete must be completely symptom free in order to begin the return to play progression. If athlete still has

symptoms more than seven days after injury, referral to a concussion specialist/clinic should he strongly considered.

Please check one of the following:

Athlete is asymptomatic and is ready to begin the return to play progression.

Athlete is still symptomatic more than seven days after injury.

Signature: ____________ Date: ______

Print or stamp name: Phone number:

Page 29: High School Hockey League of Nassau Countymedia.hometeamsonline.com/photos/hockey/HIGHSCHOOLHOCKEY… · 5. I will do my best to listen and learn from my coaches. 6. I will treat

Return to play Protocol following a concussion.

The following protocol has been established in accordance to the National Federation of State High

School Associations and the International Conference on Concussion in Sport, Prague 2004.

When an athlete shows ANY signs or symptoms of a concussion:

1. The athlete will not be allowed to return to play in the current game or practice.

2. The athlete should not be left alone, and regular monitoring for deterioration is essential

over the initial few hours following injury.

3. The athlete should be medically evaluated following the injury.

4. Return to play must follow a medically supervised stepwise process.

The cornerstone of proper concussion management is rest until all symptoms resolve and then a

graded program of exertion before return to sport. The program is broken down into six steps in

which only one step is covered a day. The six steps involve the following:

1. No exertional activity until asymptomatic for 24 hours.

2. Light aerobic exercise such as walking or stationary bike, etc. No resistance training.

3. Sport specific exercise such as skating, running, etc. Progressive addition of resistance

training may begin.

4. Non-contact training/skill drills.

5. Full contact training in practice setting.

6. Return to competition

If any concussion symptoms recur, the athlete should drop back to the previous level and try to

progress after 24 hours of rest.

The student-athlete should also be monitored for recurrence of symptoms due to mental exertion,

such as reading, working on a computer, or taking a test.

(br5/19/08)